Sunday, October 2, 2011

It's been 2 years since I put this up, and I must say that one (but only one) of the insurance companies I deal with has significantly improved in that time.

I'm not taking sides in the health care debate, but I do want to clarify something.

I see people on the news screaming that they don't want "bureaucrats" between them and their doctor, and are afraid that's what government health care will bring.

WTF? THAT'S THE WAY IT IS NOW, PEOPLE!!! I hear my assistant Annie on the phone all day trying to get approval from non-government insurance companies for tests, medications, physical therapy, ANYTHING that I order.

Look at your insurance card. Doesn't it say things like "in-network" and "formulary"? Who the hell do you think came up with those? Not us docs. Dat be dem dere byoo-row-kratz!

Look back at some of my posts (like this, or this). I routinely have medications (both brand name and cheap generics) and tests refused by insurance companies. For an excellent commentary on this from the pharmacy side, this was written by FranticPharmacist.

So if you don't want bureaucrats between you and your doctor- TOO BAD. They've been there for years. THE ONLY PEOPLE WHO DON'T HAVE THIS PROBLEM ARE PAYING CASH FOR EVERYTHING!

In fact, for those of you who don't want the government running this, THEY ARE ACTUALLY ONE OF THE BETTER ONES TO WORK WITH! Just ask Annie. Medicare doesn't question the majority of my tests, or meds. Yes, they don't cover everything, nor should they, but they don't fight with me over stuff like MRI's on stroke patients. Uncle Sam (unlike Aetna, Cigna, Humana, and many others) tends to leave these things to the doctor's discretion. Annie prefers Medicare patients for this very reason - they make her life easier.

So what happens to you the way it works NOW, with your non-government insurance?

You come to me for some neurological issue, which requires further work-up. So I order, say, an MRI and MRA of your head.

Annie gets the order, and calls Bozo Insurance, Inc. (BII) to schedule it. BII refuses, saying they want more information. So they fax us a 5 page "pre-auth" form, which Annie spends 20 minutes filling out and faxes back. Then they say the form wasn't enough, and they also want copies of your office notes, so we send those, too (yup, when you joined BII you agreed that they can read your medical records).

So a few days go by. BII will claim they never got our fax. Or that we filled the form out wrong. Or that they don't cover Capricorns when the moon is in Pisces. And we don't know this until Annie calls back after a few days, because they're hoping we forgot about it.Eventually they'll deny the whole thing, on the grounds that you don't meet criteria for an MRI and MRA. This decision is usually made by a non-medically trained person with a minimum of a GED. They do this because they want to see just how badly I want the test.

So they tell me I can appeal this via "peer-to-peer" review. Which means I need to personally call their "physician reviewer" to argue with them as to why I want the study.

So, during my insanely busy day at the office I have to call them. I'm promptly put on hold for 10 minutes, before finally reaching the reviewer. This person is a doctor- but NOT necessarily in my specialty. In fact, it's usually something like a retired dermatologist, who hasn't done neurology since medical school in 1938. Or an OB/GYN who hated his job, and is doing this now instead. Or some doctor who immigrated from Lower Swazbodiaczk and can't get a U.S. medical license (but your insurance company hired him to decide what medical care you need). But it's almost NEVER someone actually in my field, who might understand why I want the study.

So after telling your life history to Dr. Denial, one of 2 things will happen. They'll deny both studies, and want you to try medication or physical therapy or psychotherapy or holistic reflexology or whatever, and if you fail that THEN I can try to resubmit a request for the test. OR they will flip a coin and say they will cover the MRI, but not the MRA. Or vice-versa. They'll say that if the first test is fine, THEN I can start over trying to get the other covered. Maybe.

And many of these companies actually pay these "reviewers" bonuses based on HOW MUCH MONEY THEY SAVED THE COMPANY BY DENYING TESTS.

This can at times become comical. One of my patients is a doc who works part-time as one of these insurance company "physician peer reviewers". And when he needed an MRI, guess what? HIS OWN COMPANY DENIED IT! He paid out of pocket for it (and yes, it was abnormal).

So how did I get on this tangent? Because yesterday I was walking by Annie's office, and heard her losing it over the speaker phone. And, as always, she was totally awesome.

Annie: "I'm calling because you people denied an MRI on a stroke patient?"

Pinhead: "Before we discuss this, I have to inform you that this is a recorded line."Annie: "Oh, good, hopefully someone will actually be listening to me then. Thus far it hasn't happened."

Pinhead: "Let me look up the tracking number... Okay. I have to inform you that we are unable to approve this study. Your doctor will need to make a peer-to-peer call."

Annie: "Oh, now THAT's a surprise."

Pinhead: "What do you mean?"

Annie: "Is this line really being recorded?"

Pinhead: "Yes. It's to improve customer satisfaction."

Annie: "Oh, goody, because I'm sure not satisfied, and neither is the doctor, or the patient. Your company, and whoever is listening, never approves anything. In fact I can say that 100% of the time you require peer-to-peer review."

Pinhead: "We do this to save our customers money on unnecessary testing."

Annie: "Think about it. You have benefits and a salary, right? I mean you're not doing this as a volunteer job, are you?"

Pinhead: "No, but I..."

Annie: "So wouldn't your company save money by firing you and instead getting a computer that automatically denies every damn test and sends a fax telling us to call for a peer-to-peer review? Then we can just let the doctors talk directly to each other from the beginning, which is what you bozos want anyway. Think of the money saved by cutting all of your jobs."

Pinhead: "Oh, but you can't mean that?"

Annie: "Oh but I do mean that. And I'm glad we're being recorded. Let's consider the current situation. You are basically a worthless automaton. A computer could do your job for far less. And at this point you've incurred the wrath of all the medical professionals in the country as well as the patients. You and all of your superiors ought to be out of a job due to your blatant inefficiency. And don't think we don't save your denial forms, and your names, and document it all in the chart."

Pinhead: "I..."

Annie: "Nothing personal you understand, just a suggestion. I'll have my doctor call your doctor. Have a nice day".

Pinhead: "No, wait! I..."

Annie hung up.

So bottom line here: if you don't think bureaucrats are currently between you and your doctor- THEY ARE! GET REAL! IT'S BEEN THAT WAY FOR THE LAST 10 YEARS OR MORE!

47 comments:

This is why I have no intention of ever practicing in the American healthcare system. If I want an MRI on a stroke patient in Canada, I order it on our EPR and the patient gets an MRI. It's a rather revolutionary concept.

My job right now is customer service for a major healthcare company. Thankfully I only deal with medicare patients and pharmacy questions, though I'll be trained in medical claims soon enough. I feel bad enough when someone falls in the coverage gap and I have to tell them their $40 copay is now $400 out of pocket...

Annie is so completely awesome.My company, a health-care provider yet, recently announced that employees will require a physical by the company physician for their health insurance coverage. Anyone refusing to submit to the physical will be required to pay an additional $100 a month in premiums. Children, can you say "privacy violation"?

Right now, the Tories are trying their level best to turn the Canadian system into something like yours down South. Thanks, but I'd rather keep my government-run medicare. Yeah, sure, I might wait three months to see a pulmonologist (wouldn't it take about that long in the US to get it approved through your insurance? Sure takes that long for me to get my asthma meds approved through my insurance up here...), but at least I won't go broke paying for spirometry out of pocket to keep an eye on my asthma because I don't meet the criteria or whatever BS.

"Free" is a misnomer - I pay for it with my taxes. Frankly, it's worth it.

I live in Canada (BC), and yes, my Dad did get the imaging studies his doctor wanted without fuss or muss... or an appointment time any closer than 3 months out (though, the studies more or less elective in nature)

My sister's husband wrenched his knee back in high school, and his dad paid the ($400?) it cost to get the imaging studies done privately (and quickly) which meant he was able to get an appointment with the surgeon that much sooner (here, you need scans indicating abnormal pathology before you can get an appointment with a specialist).

And those that think being a self pay is any better think again. I had to buy my mom a bariatric bed not because she is overweight but because she kept rolling out of the nursing home bed and the want us to pay $60 a day to rent one.(She did not like having the railings up.)It took me going through three companys before I found one that would even talk to me since I wanted to pay out of pocket. Then I had to get a rx for the bed since she wasn't obese. Then had to get preapprovals to be selfpay to order the bed. Since it wasn't legal for them to have me prepay for it but they didnt want order it without a guarantee that I was going to pay for it.I basically had to force someone to take $2000.

Go, Annie, GO! I'm having the same struggles with a genetic condition that requires regular physical therapy/chiropractic care (I need a bone-setter for partial dislocations, and rehab to keep them in place). They just suggested P2P with my insanely busy rheumatologist. I'm going to suggest that the expert "Skype me" (I'll be a Dr. on the Ph.D. side in May, and thus a peer) so I can SHOW him the freakily loose joints I have. Children and passing strangers recognize that I have something definitely wrong. Insurance idiots on the other hand...I need to print out that conversation and use it in next Thursday's call to the analyst. Thanks, Annie!

I understand that Medicare tests/meds are rarely questioned, there is also significant amounts of fraudulent Medicare claims. These fraudulent claims cost taxpayers millions of dollars. If Medicare was a private company, it would have gone bankrupt, but because there is a never-ending steam of taxpayer money, it won't shut down. The balance to find is one where tests/meds are approved easily, but not so easily that fraud can flourish.

Yes Solitary Diner and all you other Canadians, your tests may not be questioned, but you have to wait a long time to get them. If my oncologist wants an MRI or a CT scan, I usually walk out of his office with an order and a bottle of contrast, go across the hall and have the test done. He has the results in 2 days and gives me a call. Does that ever happen in Canada? If I had to wait 3 months for a mammogram as my Canadian friend did, I would probably be as dead as she is now. There is a lot of pros and cons for both systems.

The problem is the basic way insurance works. The company takes in money, invests it and then tries to keep from paying it out as long as possible (if ever) in order to keep getting investment income for a longer time.

Emmy said: "If my oncologist wants an MRI or a CT scan, I usually walk out of his office with an order and a bottle of contrast, go across the hall and have the test done. He has the results in 2 days and gives me a call. Does that ever happen in Canada?"

Yes, that happens in Canada. (Well, except that the contrast is provided directly at the test.) It depends how emergent the need is for the test. If I see someone in my office or my emerg who has an immediately life-threatening condition, they'll get the test immediately. On the other hand, if they don't need the test immediately, they won't get it.

THAT's the main tradeoff we make: everything is triaged, and if you don't need it right away, you don't get it right away. So even if I'm wealthy, I'm not getting my knee with osteoarthritis scanned for several months. But when I come in with a sudden onset worst-of-my-life headache, no matter how wealthy or poor I am, and no matter what job I have or don't have, I sure as hell am getting whatever scans I need, immediately.

And it sucks to wait to see a surgeon for painful knees. It sucks to be told you have HSIL and to wait a few months for colposcopy. It sucks to be depressed and wait to see a psychiatrist. But the vast majority of times those wait times are appropriate to the situation -- and the vast, vast majority of the time if I have a life-threatening condition I'll get world-class care right away, no matter what my insurance situation.

There are, no doubt, frustrations in every system. There are lots of European and other systems worldwide that are probably better than the Canadian one in a variety of ways. But the US system is bizarre, unlike any other in the world, and from an outsider's point of view looks like an awful place both to practice medicine and to receive medical care.

What we need are meaningful consequences for insurance companies that delay needed treatment. As it stands now there's little downside.

Perhaps an independent review commission you can submit a case to and if they say it should have been approved (or should have been approved sooner than it was) then they get a nice fine and the doctor's office gets a chunk of that as compensation for the time spent fighting.

@ a.generic doc: That is how socialized medicine works in Great Britain too. The government health care officials decide not to authorize surgeries or treatments on purpose so that people will either purchase private health insurance or the patient dies.

You couldn't pay me enough to do what Annie does - she is a goddess! However, please reconsider referring to her as your nurse. A nurse is a licensed professional regulated by a Board of Nursing. Medical Assistants are not licensed. Essential to excellent patient care, but not a nurse.

In today's world its nearly impossible to have any large procedure without going bankrupt. Some form of health insurance is a must if you have a health condition or are prone to getting sick.

I'm glad that medicare is easy for doctors to work with, but as someone else said, it's also has a high abuse rate. These fraudulent claims cost taxpayers millions of dollars. Eventually U.S. taxpayers won't have the money, and a lot of people relying on the government wont have adequate healthcare coverage.

That being said, I think you can guess I vehemently oppose the current health care bill. Other countries have turned to similar healthcare plans, but I don't think it will benefit the U.S. at this time. I don't want to get into a political debate, but right now there are just too many problems. Just to list a few.. Not enough people are paying their taxes. Too many people are relying on the government for medicaid and welfare benefits. Not to mention illegal immigrants using emergency services without paying into the system.

I know some health insurance companies are hard to work with and are very bureaucratic, but not all companies are like that.

I personally have been using Blue Cross and Blue Shield of Nebraska for 10 years. In those 10 years, I've had some major health problems, requiring me to see over 7 specialists, needing 2 MRI's (C-Spine & Thoracic) , multiple X-Rays, countless blood tests, an unexpected ER visit, several procedures and operations, and over 1 year of physical therapy.

I'm not a doctor, nor do I work in the healthcare field, so I don't know how much of a pain they are to work with, but I can tell you that.. Out of everything I've been through, I have never had BCBS deny or reject a treatment. Even if it was very costly. They have never asked for alternative treatment before paying for something more expensive. They have never contested doctors recommendations (at least to my knowledge). And they have never challenged the need for expensive (non-generic) medications. I've also had them accept charges for early refills, even when it was due to my stupidity (dropping pills in water, etc).

Wait time to see a specialist is based on the availability of a specialist - not when my healthcare provider decides its absolutely necessary. Mind you, it still takes quite a bit of time - with the average wait 2 months for the initial visit (generally can get an appt. within the week afterwards).

I won't say BCBS is perfect, but It's a lot better than other healthcare providers that my friends use. To be honest, my only complaint with BCBS is from their billing department. I've had several problems with incorrect billing statements. I will pay the bill, then they will say the full amount had not been paid... so I send additional money. Then later in the month I will get a letter saying I overpaid, and they write me a check back. It always works out, but it can be frustrating to say the least.

Sorry for the long winded post, that I'm sure is riddled with gramatical errors, but I really wanted to share my good experience with other healthcare providers.

My husband has had debilitating knee pain and issues for 15 years. His pain management doctor wanted to do a PET scan because the MRI and CAT scan weren't showing anything that would casue his level of pain. Blue Cross denied any other course of treatment instead. However they did approve surgery number 10. How does that make sense?

My favorite part of the whole American Health Care debate is that people will strongly oppose paying X dollars a year in taxes to pay for equal, if not better coverage, than what they likely pay double for through private insurance.

Here's the difference. Annie got to vent some of her frustration at a hapless phone rep.

If the government takes it over, Annie would've have ended up on a watchlist, audited by the IRS, or hit by a no-knock warrantless midnight raid. Fed employees get a whole different level of tools to fight back with against uppity serfs.

People have simply GOT to understand this stuff, and they don't. I wish there was a way to publish this blog post in every Letter to the Editor page in the country. Dr. G., you should send in a submission to Newsweek magazine for the "My Turn" section. I really think people would be in for a real eye-opener if they could hear what really goes on from an actual medical practitioner.

Anon 8:49 - Here is the thing, I don't believe that government run health care will result in better and equal coverage for equal or fewer tax dollars. Look at Great Britain as an example; the government is running out of money and people are not getting the care they were promised. Now, my argument against socialized medicine does not mean that I whole heartedly support our current system. That is a false dichotomy on your part. I am not satisfied with our current system, but I refuse to substitute one system for another that is unsustainable and apt to fail.

Just because the federal government has meddled excessively with the medical profession doesn't excuse the practice. In my world, the costs have gone up tremendously every year for decades and the projected future costs are double digit multiples of the GDP.

I might have different opinion when there is a guarantee a drug addict won't use my tax dollars to take an ambulance for a PAP smear.

I have BCBS, though not in Nebraska. What a POS insurance company BCBS is. I've been in more than one fight with BCBS and you know what? They always win, because I have an individual policy and no clout whatsoever.

Though I'm American, I've also lived in Canada on a temporary work permit. On one occasion, I was forced to seek medical attention for a worrisome problem and was very impressed with the care I received. The docs took my symptoms very seriously (probably because I'm almost never ill) AND followed up with me a few days later. Wow.

I <3 Annie! We went to self-pay after trying private insurance. What a joke THAT was! I save SO much money now, and just bank the difference from what we were paying in premiums, in case someone needs surgery or expensive imaging. I guess you could say we're self-insured. The up side is, I get to earn interest on my own damn money and I get to decide if a test or visit is really necessary. We can see any provider we like, and typically get charged less because the office doesn't have to bill/fight anyone. It's a win/win and I kinda wish everyone paid cash so the overall cost of health care would go down. Of course, that would put a lot of people out of work, but maybe it'd be worth it.

Re: the problems in Great Britain - yes there are some problems especially for disabled people or people with some severe chronic conditions. However, I broke my arm two weeks ago, was admitted to hospital for 2 nights, have been given tramadol from the hospital pharmacy, seen specialists, had 3 sets of xrays, got transport home from the hospital and have a brace fitted. The only money this has cost me is transport back to the hospital for outpatient appointments. A friend has diabetes and never has to pay for needles and insulin as all this is paid for in taxes. I'm not sure how long this will continue though as the last government as well as the current one are trying to get more and more private companies involved which looks like it will be costing more money in the long term.

It is not legal for insurance companies to pay their peer reviewers for denying care. I've worked for multiple insurance companies, including some of the big ones you mention, and I've never been offered/paid for denying care.

URAC (see urac.org) is the accreditation organization that all these insurers belong to. They require that peer reviewers be in the same specialty that they review. This was true well before 2years ago when you first wrote this post, so I don't understand how you can possibly be reviewed by a retired dermatologist or OB GYN who hates his job. I've never been asked to review anything other than a case in my own specialty.

Most of what I do is actually quality of care. It's not just identifying waste, but preventing patients from getting really, really crappy care. (Gee, doctor, pt still having his/her acute sx. Why haven't you adjusted their meds in the last week that they've been in ACUTE inpatient care? Oh, I see. You didn't realize b/c you've had so many admits? Or, my favorite "I'm just covering. The regular doc will be back next week and I don't want to change anything.")

Many of my fellow docs operate under the Lake Wobegon effect. They all think they're above average. Unfortunately, many of them suck. I see it as my job to educate them/flag them for the health plan/get someone at the facility to do what's appropriate.

Another example of waste: I've reviewed too many hospital cases where the only reason for continued stay was that the pt's roommate/husband/case worker couldn't come pick the person up "until Friday." Right. The insurance should pay $1000/day for someone's else's convenience.

An easy example of crappy care from a review I did today: The attending spoke to the pt's wife on the phone (who he lives with) and it was apparent she had dementia. (In the same conversation, every 30 secs, she wanted to know where her husband was, when he had already told her, again and again.) They had no family support. I asked the attending if he was going to call APS (Adult Protective Services) so someone could go, do an eval, and make sure she was OK at home alone. He said no. Why? "She's not my patient." I made sure the insurance company arranged that.

There are many, many examples of care being denied that should be. I'm not saying that there are no unscrupulous reviewers (I've reviewed, for independent review organizations, many myself), but demonizing the whole lot of them is wrong.

My husband's 90 year old grandma got a same day surgery and state of the art rehab in Italy when she broke her hip a month ago. All covered by taxes that they've paid already, no fuss no mess. And Italy has one of the shittier systems over in Europe. I was duly impressed.

Still a can of worms...this go around. A peer reviewer in the field based his decision on words in my son's medical progress notes, out of context, and not anywhere near understanding their impact as to what was available out-patient. I wrote a letter explaining that my son's insurance decision-maker in discharging him early was the reason why he was re-admitted within a year of hospitalization, and sent the letter to the insurance company, the peer-reviewer's boss, and the hospital. The response from the hospital was to demand that the insurance company review the case and make a more beneficial decision to the patient (which would affect the insurance company). And, the hospital quoted statements from my son's medical record that gave conflicting and acrimonious rationale for coming to the peer-reviewer decision. I am not saying that reviewers are unscrupulous, nor am I defending anyone other than my son, but the physician that cared for my son every day while he was in the hospital had way more validity than what someone reading his records out of context. In a business office in an entirely different part of the country someone might have an entirely different mien, or point of view than the actual practitioner--medically-trained corporate minion versus medically trained physician. When I was training for the hospital pharmacokinetics service, my mentor could not stress enough his underlying theme--for God's sake, look at the patient, we're not in the business of turning out widgets.

I love Annie! Wish I'd had her on hand to turn loose on the morons at BCBS in Oklahoma years ago. Two docs said I needed surgery, BCBS said no, I didn't meet the criteria. Well, what's the criteria? I don't know, the review panel decides that. Well, let me talk to them. No, you can't talk to them, they don't deal directly with patients! And around and around we went until I was a day away from showing up in their corporate office, unannounced and royally pissed off.

tl;dr My doc finally got the surgery approved. Hmm, maybe Annie used to work for him.....

“BII will claim they never got our fax. Or that we filled the form out wrong.”

I work in medical records and this drives me crazy. We get a fax saying approval is pending receipt of a list of documents. I look in the chart and see that you sent an identical notice three days ago and my co-worker listed a bunch of documents she faxed. Did you not receive the fax? Did you receive it and not review it yet? Do I re-send the same documents or assume you already have those and send something new? Why not say, "Thanks for sending ABC but we still need D"?! Seriously who is saving money in all this?

Amen!I would rather have a gov't entity who's not trying to make a profit on my illness make decisions on coverage than a corporation who keeps paying it's execs multimillion dollar bonus for screwing the patient.Love your blog, Doc!

re: URAC (see urac.org) is the accreditation organization that all these insurers belong to. They require that peer reviewers be in the same specialty that they review....

BULLSHIT. I had a RADIOLOGIST DENY A SCAN ON ONE OF MY ONCOLOGY PATIENTS BECAUSE THE PATIENT RECENTLY HAD A SCAN (PAID FOR BY THE STUDY). YOU OBVIOUSLY DO NOT KNOW WHAT YOU ARE TALKING ABOUT. KEEP ON TAKING YOUR INSURANCE COMPANY PAYOFF MONEY....SCUMBAG.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

Singing Foo!

Have Dr. Grumpy delivered automatically to your Kindle for only 99 cents a month! Sign up here!

Dr. Grumpy is for hire! Need an article written (humorous, medical, or otherwise) or want to commission a genuine Grumpy piece for your newspaper/magazine/toilet paper roll? Contact me to discuss subjects. You can reach me at the email address below, or through my Linked-In profile.

Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.